IMPLEMENTATION OF DISASTER PLAN

REVIEW SHEET
Disaster Plan implemented by:________________________________________
Date of implementation:______________________
Reason of implementation:
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
Was this an internal disaster?

______YES ______NO

Was this an external disaster?

______YES ______NO

Was disaster callback initiated?

______YES ______NO

By whom? _____________________________________________________________
Type of disaster: (Specify) _________________________________________________
Briefly, but completely describe the events surrounding the disaster:
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
Were communications adequate?

___YES ___NO

Did Chief of Staff place physicians in needed areas?

___YES ___NO

Were any victims or patients transferred?

___YES ___NO

How many? ___________Why?_____________________________________________________

Were area hospitals notified of the disaster and prepared to help?

___YES ___NO

Was the fire department available?

___YES ___NO

Was the police department available?

___YES ___NO

What community agencies were involved?

____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________

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IMPLEMENTATION OF DISASTER PLAN

REVIEW SHEET
Were hospital patients assessed for discharge if beds were needed for disaster victims?

___YES___NO

How many patients were in the hospital at the time of implementation of the disaster plan? _______________
How many visitors were in the hospital at the time of implementation of the disaster plan? ________________
How were the departments staffed?
DEPARTMENT

ON DUTY

CALLED IN

TOTAL

ADEQUATE

Administration

_______

_______

______

______

Business Office

_______

_______

______

______

Purchasing

_______

_______

______

______

Dietary

_______

_______

______

______

Pharmacy

_______

_______

______

______

Maintenance

_______

_______

______

______

Housekeeping

_______

_______

______

______

Radiology

_______

_______

______

______

Laboratory

_______

_______

______

______

Respiratory

_______

_______

______

______

Physical Therapy

_______

_______

______

______

Medical Records

_______

_______

______

______

Nursing

_______

_______

______

______

Operating Room

_______

_______

______

______

Central Service

_______

_______

______

______

Recovery room

_______

_______

______

______

Medical Staff

_______

_______

______

______

If there were other categories of individuals in the hospital at the time of implementation of the disaster plan, please list
the category (e.g., construction workers, etc.):
CATEGORIES:
________________________________________

NUMBER:
______________________________________

________________________________________

______________________________________

________________________________________

______________________________________

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IMPLEMENTATION OF DISASTER PLAN

REVIEW SHEET
Was hospital protocol followed?

___YES___NO

Did staff respond according to protocol?

___YES ___NO

Did supervisory personnel respond according to protocol?

___YES ___NO

Please explain any negative answers:

_______________________________________________________________________________________________
_______________________________________________________________________________________________
How long did it take staff to respond once the disaster plan was implemented?________________________
How long did it take for supervisory personnel to respond once the disaster plan was implemented?_______________
Were problems encountered with patients, visitors, or other individuals while the disaster plan was in effect?
___YES ____NO
Please explain problem areas:
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
Was corrective action taken at the time the problem(s) were identified?

___YES ___NO

Explain the corrective action:

_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
Is there a need for future corrective action?

___YES ___NO

Explain:
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
Overall implementation, response, and process of the disaster plan was:
Excellent________

Good ________

Fair________

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Poor________

IMPLEMENTATION OF DISASTER PLAN

REVIEW SHEET
Could anything be done differently?

____YES___NO

Explain:
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
Were monitors selected to evaluate drill?

____YES___NO

Where? _____________________________________________________________
Immediately after the drill, what groups participated in critique?
Nurses ____YES___NO

Physicians ____YES____NO

Administration

Fire

Police

Hosp. Personnel ____YES___NO

____YES___NO

Ambulance Personnel

____YES____NO

____YES____NO

Emergency Management

____YES____NO

____YES____NO

Other:
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
Title of Person Completing Form:______________________________________________

________________________________
Signature

________________________
Date

Source: Muskogee Regional Medical Center, Muskogee, Oklahoma. Used with permission.

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